Barbados is in the grip of a diabetic foot amputation crisis

“If you go to the hospital, your foot comes off”

Barbados is considered a high income country,6 with a healthcare system that provides access to treatment and essential medications free at the point of care, which makes the progression of diabetes to secondary complications at such alarming rates perplexing. A 2004 study reported an incidence of 936 amputations per 100 000 people with diabetes in Barbados, noting specifically that Barbadian women had amputation rates second only to the Native American Navajo tribe in the United States.7 Subsequent research, analysing data up to 2009 and published in 2017, indicated a 10% rise in the prevalence of diabetes across all amputation cases in the country,8 intensifying the need to investigate this risk factor.

Laura Lovell, a general practitioner with a specialist interest in diabetes and principal investigator of the recently launched Barbados diabetic foot study at the University of the West Indies, Cave Hill Campus, is determined to establish a comprehensive view of this ongoing challenge. Quantitative data collection began on 1 January 2024, with a report of findings expected in 2025. Lovell initiated the study after making some worrisome observations in clinics. “I did a study where I worked to see what the comorbidity risk was, and we saw that every single person in the foot clinic had eye disease, kidney disease, and very established cardiovascular disease as well,” she tells The BMJ. “These will also be factors we look at in the Barbados diabetic foot study.”

Her findings so far, from the qualitative focus group arm of the study, show that public fears might be delaying people with diabetes from seeking treatment for limb complaints, rooted in a lack of understanding the progression of complications. “The man on the street thinks that if you go to the hospital, your foot comes off. I think that’s a big disconnect that’s going on,” she adds, further evidence of the multifaceted nature of the root causes.

Deep roots

“There’s a consequence of development,” says Damian Cohall, dean of the Faculty of Medical Sciences at the University of the West Indies, Cave Hill Campus, emphasising the complexities of the epidemiological “nutrition transition” that accompanies increased wealth and urbanisation. This transition refers to predictable shifts in dietary patterns as countries modernise and grow economically. Researchers categorise it into five stages: from the highly active, protein rich diets of hunter-gatherers (pattern 1) and the famine prone early agriculture phase (pattern 2) to the diminishing famines and improved nutrition in societies with rising incomes (pattern 3). Pattern 4 is marked by overconsumption and sedentary lifestyles leading to obesity and related chronic diseases like diabetes and heart disease. Eventually, the transition culminates in pattern 5, in which behavioural changes and community efforts aim to counter these health problems.9 For Cohall, this is only part of the puzzle.

Cohall’s faculty, working with the George Alleyne Chronic Disease Research Centre, conducted follow-up studies between 2007 and 2016 that helped identify mutations in a gene that can lead to higher levels of free radicals in human tissues, especially blood vessels, which generally prolong inflammation.10 “We also found that . . . the regional oxygen saturation of our tissues was also very limited and that extrapolates quite well with what we found regarding macro and microvascular complications as it relates to diabetes,” adds Cohall. These factors—genetic risk and its influence on inflammation and regional oxygen saturation—were identified as potential predictors of developing diabetic ulcers and of poor outcomes related to survival after amputations.

Cohall thinks that insights from Barbados are especially pertinent for African populations. “When you look at the historical background of the island, you realise that there was not much mixing between . . . ethnic groups, unlike some of the other islands like Trinidad or Jamaica, where there were a lot of indentured servants that came in after the abolishment of slavery that didn’t happen in Barbados.”

“What you have, essentially, is a very homogeneous group of Africans in Barbados, and that has always made Barbados a very good study population for looking at genetic studies that could essentially speak to the predictive nature of some diseases within our population,” he says. Barbados with its high income status could represent the most likely state of affairs for populations across countries on the African continent as they continue to undergo nutrition transitions if nothing is done to halt this epidemiological trend.

Mobilising against the tide

In January 2023, against the backdrop of escalating non-communicable diseases in the region, WHO convened a high level technical meeting on non-communicable diseases and mental health in small island developing states in Barbados. Among five key points published in the meeting report was the need to combat “commercial determinants of health and conflicts of interest.”11 But balancing public health interests with policies that encourage industry investment is a major challenge. Barbados experienced robust opposition when it introduced a 10% tax on sugary drinks in 2015, which intensified in 2022 with a rise to 20%.

Some health advocates in the region think that industry players are obstructing healthy food policy initiatives.12 This resistance coupled with economic considerations might have influenced some governments to opt for collaborative approaches over confrontation in tackling such health challenges. In April 2023, for example, the prime minister of Barbados announced the “Coca-Cola Caribbean Calorie Counter” tool aimed at improving nutritional management13—Coca-Cola being the island’s leading producer of sugar sweetened beverages.

“We tend to import most of our foods from the US, Europe, etc, and as a result, our diet is heavily westernised,” says Payne. This year he and colleagues at the Ministry of Health and Wellness are “pushing towards a ban of all trans fatty acids in foods by December (2024),” but he states that, in a personal capacity, taxes and bans, which serve as deterrents, are not enough.

“I think the challenge is that the cost of living here is extremely high. If you think about eating any kind of healthy diet, you’re definitely going to spend a significant amount of your money . . . the big fear for me is telling people who are struggling financially to buy the fruits, buy the vegetables, which are very expensive.” Payne adds, “My thinking, on a personal note, is [whether] some of this revenue [could] be earmarked to reduce the cost of things like fruits and vegetables, or to fund schools to purchase equipment to boost physical activity. I know politicians aren’t very happy to earmark monies.”

Acknowledging the confluence of socioeconomic factors, economic realities, and health policy implementation, sets the stage for viewing Barbados as not only a nation in pursuit of solutions, but also a microcosm of a global challenge. Genetics, for example, is clearly a factor, says Cohall, but what allows these diabetic complications to develop in Barbados is really the environmental factors that allow those genes to be expressed—namely diet.

“We can’t do anything about our genes, but we can certainly change the environment. And we can certainly change the environmental factors—that is where the focus should be.”